The field of Interventional Radiology has long been a fast-paced, ever-shifting one, but soon it appears that the landscape and infrastructure too, will shift. MACRA is a certainty; the senate approving a budget reconciliation bill containing a revised version of AHCA is merely a possibility. However, it is important for young aspiring interventionalists to attempt to anticipate the whirlwind. I’ll try to provide a brief background and what it may forebode.

MACRA, or the 2015 Medicare Access and CHIP Reauthorization Act, attempts to replace the current CMS reimbursement system, SGR or sustainable growth rate, by including quality metrics, meaningful use, quality improvement efforts, and use those to create a ranking system through which some physicians will be more highly reimbursed than their peers based upon higher scores. For a specialty such as IR, this is particularly meaningful, because besides the dent in the pocketbook a low rank may cause a referral-based physician such as an Interventionalist to lose out to higher-ranking members.

It is likely, therefore, that these rankings may significantly influence the reputation of a practice, for reasons sometimes outside of the Interventionalist’s control. Those that are employed by large health systems may be shielded from losing money by their guaranteed salary, but they are at the mercy of the system for a large portion of their score—as much as 25% of which is determined by “advancing care information/EHR meaningful use”, which the hospital system would determine. Similarly, 15% would be decided by clinical improvement programs, for which funding and implementation would again, rely upon a hospital system that may be large in scope and heavy in bureaucratic red tape. What the independent interventionalists gain in maneuverability, they may risk with vulnerability; a poor MACRA score may prevent clinician referrals, or have patients looking for higher scoring Physicians—Physician Compare is a tool slated to be ready in 2019 that reveals MACRA scores to the public, which will let anybody with an internet connection know how much less you’re being reimbursed than the next catheter jockey.

By the year 2022, the worst scoring physicians will receive 9% less than average. The best, 27% more. A 36% wage gap between “the best” and “the worst” will certainly influence the job market—no doubt, those that earn higher reimbursements will be more desirable. Your resume may include fluency in several languages and a working knowledge of Excel, but MACRA mastery may be the buzzword your future health system is seeking. Similarly, groups may look to prune the micro-MACRAs, as in those that do not reimburse at an acceptable rate, both to prop up the group’s reputation and their bottom line.

But there may be a smaller pool of patients to compete over. The AHCA, as it was passed by the house, would cut Medicaid funding by 30% by the year 2027. And that is in addition to leaving another 24 million uninsured entirely, as current estimates by the Washington Post project. Many of the uninsured would be removed from Medicaid benefits themselves, as a provision allows denial of Medicaid to those that recently got off of it—in other words, those that may go from unemployed to employed to unemployed again, might find themselves without recourse. While these cuts aren’t assured as the bill is being rewritten in the Senate, and may not pass even then, they would carry important repercussions if they did-the vast majority of patients undergoing an IR procedure are insured or on Medicaid, and cuts of this magnitude would ensure a patient volume crunch which has never affected the specialty before. Now more than ever, increased specialization, strong referrer relationships, advertisement and marketing must make their way into the skillset of young interventionalists, because it seems that in the near future, uncertainty is certain.

References:

Advocacy in Action eNews. (2017 March 17) ACR-SIR: How to Thrive Not Just Comply With MACRA. Advocacy in Action eNews. Retrieved from acr.org

Bump P. (2017 May 5) Estimated decline in number of insured where Republicans backed the AHCA? 11.6 million. Retrieved from Washingtonpost.com

J. Eilperin and A. Goldstein. (2017 May 4) What is in the Republican health-care bill? Questions and answers on preexisting conditions, Medicaid and more. Retrieved from Washingtonpost.com

Krol Katharine L. (2016 May 11) Everything You Need To Know About MACRA Implementation (But Were Afraid To Ask). Retrieved from SIRConnect.org

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